OLUMBIA, Mo. — Diversity is a big problem at medical schools around the country, but perhaps no more so than here.

The University of Missouri School of Medicine is in danger of losing its accreditation next year because it has so few minority students and faculty. There are five black students in the current first-year class, out of 104 students. In 2015, there were two. The year before, there was just one.

This is the third time since 2000 that the school has been called out for its lack of diversity. And this time, the school is moving aggressively to convince students of color to move to the middle of Missouri to fulfill their dreams of becoming a doctor.

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“We have a real issue we need to deal with,” said Dr. Patrick Delafontaine, dean of Missouri’s medical school.

The school is trying everything from individual outreach to minority students to building ties with historically black schools to offering more minority scholarships to expanding programs that prepare students for the rigors of medical school. It has launched a minority lecture series to expose students of color to successful physicians who look like them.

But in interviews with STAT, more than a half dozen current and former students described a campus that has made it harder for them to succeed. Some said that MU’s lack of diversity means they are more likely to be mistaken for a janitor, to be singled out for ID checks by campus security, or to hear physicians make off-handed remarks about patients of color. They said it was more difficult for them to thrive here than white students. They said they have dealt with subtle and overt displays of racism. And some have questioned whether they made a mistake deciding to attend the school.

This dissatisfaction could have dire consequences: If the school loses its accreditation, a medical degree from here could be rendered essentially worthless.

Several students and alumni said they believe the effort could succeed. But they lamented that there was little they could do about the here-and-now, and the institutional hurdles standing in the way of finishing their medical education.

“There are plenty of things the school hasn’t done a good job of — and there are still stragglers of that old guard that do a disservice to students,” said Samiat Agunbiade, a fourth-year student. “The school is headed in the right direction. But it’s hard to know if it’s going to be enough.”

‘We have a real issue’

As Missouri tries to hang on to its accreditation, it needs to win over prospects like Leslie Fogwe, a 24-year-old native of Cameroon. Fogwe was accepted into two medical schools: Missouri med school and the University of Alabama, Birmingham. Alabama has a better academic ranking and is slightly more diverse. But Missouri has one built-in advantage: Leslie’s brother, Delvise, attends medical school there, and speaks highly of his experience.

“I went to my brother’s white coat ceremony. He filled me in and said they needed diverse students. I’ve tried to go in with a blank page and learn more about the school, the program, and the need for diversity,” said Fogwe, who is about to graduate from Delaware State University.

Leslie’s brother is one of the five black students in the Class of 2020.

Some MU officials acknowledge their failures to move the needle on diversity after their first two citations from the national accreditation organization, the Liaison Committee on Medical Education, in 2001 and 2008. In its 2016 ruling, the LCME said the medical school still faces challenges “that inhibit the enrollment of students and the hiring of faculty in the full range of diversity … to maintain a quality learning environment.” Missouri must now recruit more black, Hispanic and Native American students by 2018.

“It was disappointing but not surprising,” said Delafontaine.

Over the past decade, the LCME has cited nearly half of all US medical schools for lacking diversity. Even prestigious schools like Yale and Stanford have struggled to graduate students of color, according to data from the Association of American Medical Colleges.

Leslie Fogwe, 24, has been accepted to the University of Missouri School of Medicine.Suchat Pederson for STAT

‘The history isn’t lost’

In the last two years, this college town has seen much racial turmoil, after a large-scale student protest that followed a series of race-related incidents at the university.

Columbia is in the heart of a state that is 83 percent white. The university remained segregated until 1950. Minority students have protested their treatment over the decades.

The aftermath of the student protests, which also followed the 2014 shooting of Michael Brown two hours away in Ferguson, greeted LCME accreditors when they reviewed the medical campus in January 2016, two months after the university system president resigned in response to a boycott by the football team.

“The history isn’t lost,” said Dr. Veronica Catanese, LCME co-secretary. “When the LCME goes out for a review, they’re aware.”

On site, LCME accreditors found the percentage of underrepresented minority faculty was even lower than students, right below 6 percent. According to the report, medical school deans agreed with the accreditors that its diversity was “unsatisfactory.”

Catanese said medical schools generally set their own diversity goals, which the LCME then tracks. Missouri had improved its geographic diversity, growing its number of rural students, but failed to do the same for racial diversity. Rather than set a goal of a number of students, the school proposed changes to recruiting and programming.

But for students, a lack of diversity can have a profound effect on education. It can mean a lack of camaraderie — critical for success in the school’s team-based curriculum. Minority students told STAT they had trouble fitting in, and it led to isolation, poor grades, and even failed exams.

It can also mean a lack of perspective. Colbey Ricklefs, a white student, said classmates of color bring life experiences to the table that white doctors can learn from. For example, he believes having black students who can talk about historical distrust of the medical profession can give “voice in the classroom about a lived experience.”

“Not having that identity present in the room can mean we miss topics entirely,” Ricklefs said.

Fogwe, who suffered from malaria as a child in a one-doctor town, points to the changing population in the US as another reason why medical schools need to diversify.

“The patient base is changing to become more diverse,” he said. “I think a patient might want to relate with someone who looks more like them.”

At its worst, inadequate diversity can cause students to leave medical school. Josiane Tossa was the only black student to begin at MU in 2014. She left before her first year ended because she felt isolated and lacked support and understanding from her faculty mentor.

“I was made to feel like I wasn’t going to be successful — and that I was at fault,” said Tossa, now studying to be a physician assistant at George Washington University. “It would’ve made a world of difference if I wasn’t the only one in my class.”

‘They don’t like black people’

He may be guilty of wishful thinking, but the most hopeful leader at the University of Missouri is Warren Lockette, the senior associate dean for diversity and inclusion. Last fall, he told Delafontaine that he would build the most diverse medical school in the country in one year.

Earlier this year, Lockette took about 30 medical students to meet Dr. Otis Brawley, the chief medical officer of the American Cancer Society, during a trip to Atlanta. Brawley spoke about his own upbringing, and offered advice on being a minority in medicine.

Lockette hopes outings like this show minority students they have support at Missouri. Another way is by promoting black faculty to visible positions in administration. Dr. Laine Young-Walker, a longtime clinical psychiatry professor, was recently named associate dean of student programs.

Students here said Young-Walker could finally spur changes they hope to see. But improving diversity is daunting: Missouri must fight over a small pool of medical school applicants nationwide — underrepresented minorities make up only 15 percent of applicants.

In recent years, they’ve received more applications from these groups, but most accept offers to other schools. Because many students need financial support, Missouri offers eight scholarships to students “traditionally underrepresented in medicine” and allows others to qualify for in-state tuition after one year.

Missouri launched minority interview days last fall, and dispatched faculty to visit historically black colleges and universities to recruit to minority premed students. By 2018, it will roll out a program to help Missouri’s minority undergraduates get ready for medical school and a postbaccalaureate program to help those with science backgrounds prepare as well.

As part of its efforts, Missouri has invited St. Louis-area high school students to the medical school — and has med students volunteer with younger minorities in Columbia. Lockette wants Missouri to find more ways to expose children to medicine at an earlier age.

“Whatever it is I can do to help,” he said, “I’m willing to provide it.”

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That’s a far cry from Young-Walker’s experience here in the early 1990s. “My mom said, ‘Don’t go there, they don’t like black people,’” she said, recalling an incident in which someone put a picture of monkeys on the door of a fellow black student. Still, Young-Walker stayed through her fellowship before becoming faculty.

To her, early diversity initiatives seemed like “lip service” to please accreditors. This time, Young-Walker says it’s different.

“I’ve since seen a true desire and spirit for change,” she said.

Reaching a ‘critical mass’ nationwide

Medical schools nationwide face a diversity crisis. Only 6 percent of US doctors identify as black, Latino, or Native American — even though 32 percent of Americans considers themselves as such. In the 1960s, a decade after Missouri accepted black students, the University of California, San Francisco, integrated. By the 1980s, UCSF had surpassed most medical schools in diversity. That school’s vice dean for education, Dr. Catherine Lucey,‎ said the medical school wanted its students to reflect the nation’s diversity.

“Diversity must be a true manifestation of values,” Lucey said, “not an accreditation decision.”

But without accreditation, medical students can’t apply for residency programs. The LCME rarely revokes accreditation, but did so briefly in the case of San Juan Bautista School of Medicine in 2011. Typically, the LCME acts only if a school fails to correct series of citations — not just one, such as diversity. (Missouri med school was deemed out of compliance in four out of 95 categories that make up LCME’s 12 standards.)

Because of such inaction, MU students seem unfazed by the threat of losing accreditation. They feel like deans will do enough to maintain its full standing with the LCME — even if, in their eyes, they’ll be gone before things change.

Change can happen. When UCSF’s Class of 2020 arrived, about a third were underrepresented minorities. Lucey said the schools has rethought its admissions process — less focus on MCAT scores, more focus on life experiences — to reach a “critical mass” of minority students. It’s helped minority students who feared potential cultural isolation consider USCF.

At MU, said Dr. Ontario Lacey, a Missouri med school alum who’s an internist with Naval Medical Center in San Diego, being one of few can lead to misunderstandings.

“We’re told we don’t communicate well, when we may communicate differently,” he said. “It’s hard to prove someone is biased toward you.”

Matthew Bartley was one of a few black students to graduate in 2016. He said he was dinged in a third-year rotation for “unprofessionalism” and “trying to avoid work,” even though, he said, he was showing up early to work and treat patients respectfully.

He was shocked.

“I changed my behavior,” said Bartley, now a surgery resident at the University of Colorado, Denver. “I became a robot who did my work. I felt so nervous something was going to happen again.”

To improve Missouri med school’s diversity, Bartley thinks alumni should play up the positives about the educational experience while remaining frank about the hardships. Deans see their efforts already paying off after getting 60 percent more applications this year from underrepresented minorities.

Still, the question remains: Will minority students accept offers with the LCME report hanging over MU’s head?

Fogwe’s acceptance letter from the University of Missouri School of Medicine. This image has been altered to protect Fogwe’s privacy.Suchat Pederson for STAT

To some degree, Fogwe has prepared for the lack in diversity, as he specifically applied to medical schools with few minorities to increase his chances of acceptance. He’s one of 22 underrepresented minority students accepted for the next academic year.

Last year, Missouri med school had a lesser percentage of underrepresented minorities enrolled than Alabama.

In the end, Fogwe decided to head to Columbia, where in July he will start the pursuit of his white coat.

Yet the biggest factor may not have been the outreach by the school, but the fact that his brother, Delvise, sold him on Missouri’s strengths. He told his brother of the school’s curriculum, friendly staff — and that the two could get to live together. It only helped that Missouri med school offered Leslie a full ride.

“It’s a better choice for me,” Fogwe said. “I’m assured by the actions. I’d be willing to help in the process in any way.”

I think Susan Wilson’s comments on students wanting to see faculty members and patients who “look like them” demeaning to any aspiring professional.

“Not fitting in” causing failing grades?

Give me a break.

I attended KU Med School 40 years ago we never got any breaks and open humiliation in front of your peers was just par for the course. Faculty said they were “protecting society” by not graduating mediocre doctors. Residency was even worse, in those days frequently 100+hours a week. Most of the surgical residents divorced: if they weren’t at the hospital, they couldn’t be in the OR.

I found the practice of medicine over forty years to be a continuing process of introspection, always questioning yourself if you were on the right track or not. Oftentimes you realized your assumptions were incorrect. In other words, wasn’t not for the light hearted. It wasn’t easy. But like they said in “League of their own”, it it was easy, anyone could do it.